Underwriter: - Excess



Underwriter: Broker: Date:

EARTHQUAKE APPLICATION

This application forms and becomes part of your insurance policy

|I N| |

|S U|Named Insured: Effective Date: |

|R E| |

|D |DBA: |

| | |

| |Mailing Address: |

| | |

| |Location Address: Entity: |

| |Coverage must be 100% replacement cost | | |Deduc |

| | | | | |

| |Building: $ |Earthquake Sprinkler Leakage: Yes No |Mold Clean-Up |2% |

| | | |And Removal Coverage: |5% |

| |Contents: $ |Ordinance or Law: | |7.5% |

| |Business Income/EE: $ |None 10% 20% |$10,000 (bldg only) |10% |

| |APC: $ Pools Fences Paved Surfaces | |25% All Cov. |15% |

| |Coverage for Business Income/Extra Expense and Additional Property Coverage|Tenants Improvements: |50% All Cov |20% |

| |is provided on a per location basis. |$ | | |

1. Year Built:

2. Total # of Stories:

3. Total Building Area:

4. Total # of Buildings:

5. Occupancy:

a. Agri-Business

b. Apartment

c. Condo Association

d. Hotel/Motel

e. Manufacturing

f. Office

g. Public Building

h. Restaurant

i. Retail

j. School

k. Service

l. Warehouse

m. Wholesale

6. Construction Class:

a. Brick Veneer

b. Fire Resistive

c. Joisted Masonry–Reinforced Masonry

d. Joisted Masonry–Tilt Up

e. Joisted Masonry–Un-Reinforced Masonry

f. Masonry Non-Combustible

g. Modified Fire Resistive

h. Non-Combustible

i. Wood Frame

7. Parking Class:

a. Attached – No structure above

b. Detached

c. First Floor Parking

d. Full Subterranean

e. Habitational Over Garage (HOG)

f. Partial Subterranean

g. Soft First Floor

h. Tuck Under – 1 side

i. Tuck Under – 2 sides

j. None

8. If building was built prior to 1940, when was/were the building(s) updated?

9. Is/are the building(s) bolted to the foundation?

(wood frame or modular only)

Yes No

10. Does risk have flood coverage?

Yes No

PERSON TO CONTACT FOR INSPECTION:

TELEPHONE #:

PRODUCER

SIGNATURE:

DATE:

If more than one building OR location, please complete the following as part of the application

If building is wood frame, please advise whether the building is bolted to the foundation

Loc # |

Bldg # |

Street, City, State, Zip |

Building Value |

Contents Value |

T.I.B |

Business Income |

Year Built |

Construction Type |

Area/

Sq Ft |

# of

Story |

Type of Parking |

Occupancy | |      |      |      |      |      |      |      |      |      |      |      |      |      | |      |      |      |      |      |      |      |      |      |      |      |      |      | |      |      |      |      |      |      |      |      |      |      |      |      |      | |      |      |      |      |      |      |      |      |      |      |      |      |      | |      |      |      |      |      |      |      |      |      |      |      |      |      | |      |      |      |      |      |      |      |      |      |      |      |      |      | |      |      |      |      |      |      |      |      |      |      |      |      |      | |      |      |      |      |      |      |      |      |      |      |      |      |      | |      |      |      |      |      |      |      |      |      |      |      |      |      | |

CONSTRUCTION SYMBOLS:

BV: BRICK VENEER FR: FIRE RESISTIVE JMR: JOISTED MASONRY-REINFORCED MASONRY JMT: JOISTED MASONRY-TILT UP M: MODULAR

WF: WOOD FRAME NC: NON-COMBUSTIBLE JMU: JOISTED MASONRY-UNREINFORCED MASONRY MCN: MASONRY NON-COMBUSTIBLE

What is the building shape? Does the building have setbacks and/or overhangs? These characteristics impact the performance of buildings

Regular (square, rectangular, circular) Yes in seismic events and are a part of our rating system. They

Irregular (all other buildings shapes) No will be verified at inspection and may be endorsed to reflect

Unknown Unknown reflect the correct building attributes. Additional eligibility

changes will apply based on soil type, liquefaction, territory,

construction type, age, and parking type.

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